Primary maturation failure of arteriovenous fistulas for hemodialysis: Risk factors and impact on survival

Introduction: Primary maturation failure (PMF) remains a major limitation of autologous arteriovenous fistulas (AVFs) for hemodialysis and may increase long-term catheter dependence. We aimed to identify predictors of PMF and evaluate its association with survival outcomes. Methods: We conducted a retrospective single-center cohort study including adult patients undergoing first AVF creation between 2016 and 2020. PMF was defined as failure to achieve a functional AVF suitable for hemodialysis within 3 months according to clinical and Doppler ultrasound criteria. Predictors of PMF were analyzed using multivariable logistic regression. Overall survival was evaluated using Kaplan-Meier analysis and Cox proportional hazards models with follow-up truncated at 4 years. Results: A total of 413 patients were included; PMF occurred in 124 cases (30.0%). Patients with PMF had smaller preoperative vein diameter (2.68 ± 0.49 vs. 4.02 ± 3.56 mm; p < 0.001) and a higher proportion of distal AVFs (43.1% vs. 23.9%; p < 0.001). In multivariable analysis, preoperative vein diameter was the only independent predictor of PMF (OR 0.13, 95% CI 0.07–0.25; p < 0.001). During follow-up, 113 patients died. Overall survival did not differ between patients with and without PMF (log-rank p = 0.938), and PMF was not independently associated with mortality after adjustment. However, among patients with PMF, prolonged catheter exposure was independently associated with increased mortality (HR 3.29, 95% CI 1.64–6.59; p < 0.001). Conclusions: PMF was primarily associated with preoperative venous anatomy and was not independently associated with mortality. However, persistent catheter dependence after PMF identified a high-risk subgroup with increased mortality. These findings highlight the importance of careful preoperative vascular assessment, continued prioritization of AVF creation, and strategies aimed at minimizing prolonged catheter exposure after initial maturation failure.